Treatment of Shingles (Herpes Zoster)
Start oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, ideally within 48-72 hours of rash onset, for all immunocompetent patients with herpes zoster. 1
Antiviral Therapy for Immunocompetent Patients
The cornerstone of shingles treatment is oral antiviral medication, which should be initiated as early as possible:
First-Line Oral Antivirals (Choose One):
Valacyclovir 1 gram three times daily for 7 days - This is the FDA-approved regimen and offers excellent efficacy with convenient dosing 1
Famciclovir 500 mg three times daily for 7 days - Equally effective alternative with comparable outcomes to valacyclovir 2, 3
Acyclovir 800 mg five times daily for 7 days - Effective but requires more frequent dosing, which may reduce compliance 4, 5
Timing of Antiviral Initiation:
Optimal window: Within 48-72 hours of rash onset - This is when antivirals are most effective at reducing acute pain, accelerating rash healing, and preventing postherpetic neuralgia 1, 4, 5
Beyond 72 hours: Still consider treatment - Observational data suggests valacyclovir may still provide benefit when started later than 72 hours, particularly for pain reduction, though ideally treatment should begin as soon as possible 3
Key Clinical Considerations:
Valacyclovir offers practical advantages: The three-times-daily dosing improves compliance compared to acyclovir's five-times-daily regimen, and research demonstrates it resolves zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 3. A twice-daily 1.5 gram regimen has also shown comparable safety and efficacy 6.
Special Populations Requiring Intravenous Therapy
For immunocompromised patients with severe disease or complications, use intravenous acyclovir 5-10 mg/kg every 8 hours until clinical resolution is achieved. 7
- This includes patients with HIV, those on chemotherapy, or those with other immunosuppressive conditions 8, 7
- Treatment duration may need to be prolonged beyond the standard 7 days until complete clinical resolution 7
Urgent Indications for Antiviral Therapy
Certain presentations require immediate antiviral treatment regardless of timing:
- Age ≥50 years - Highest risk for postherpetic neuralgia (30% at 6 weeks, 15.9% at 6 months, 9% at one year) 5, 9
- Herpes zoster ophthalmicus or any head/neck involvement - Risk of serious ocular and neurological complications 5
- Severe disease on trunk or extremities - Extensive rash or systemic symptoms 5
- Immunocompromised patients at any age - Higher risk of dissemination and complications 5
Pain Management
Combine antivirals with appropriate analgesics and consider adding a neuroactive agent like amitriptyline for optimal pain control. 5
- Adequately dosed analgesics should be started concurrently with antivirals 5
- Narcotics may be required for severe acute pain or established postherpetic neuralgia 4
- Tricyclic antidepressants (e.g., amitriptyline) or anticonvulsants in low doses help control neuropathic pain 4, 5
- Topical options include capsaicin cream or lidocaine patches for localized pain 4
Role of Corticosteroids:
- May provide modest benefit for acute pain reduction but does not significantly prevent postherpetic neuralgia 5
- Consider as adjunctive therapy in select cases, but not as primary treatment 5
Patient Education and Infection Control
Advise patients that lesions are contagious to individuals who have not had chickenpox until all lesions have crusted over. 8, 7
- Patients should avoid contact with pregnant women, newborns, and immunocompromised individuals during the contagious period 8
- Emphasize that antivirals are not a cure but reduce severity and duration of symptoms 2
- For patients at risk of postherpetic neuralgia (age ≥50, severe initial pain, or viremia), early referral to pain specialists may be warranted 9
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours unnecessarily - While earlier is better, don't withhold antivirals from patients presenting later, especially those at high risk 3
- Underprescribing antivirals in high-risk patients - Studies show 50% of elderly patients at highest risk for postherpetic neuralgia don't receive appropriate antiviral therapy, often due to rigid adherence to the 72-hour rule 9
- Inadequate pain management - Pain control should be aggressive from the outset, not just reactive to established postherpetic neuralgia 5
- Missing ocular involvement - Any herpes zoster in the ophthalmic distribution warrants ophthalmology referral to prevent serious complications 4, 5